Reconstructive Skin Surgery
Plastic surgery is a fascinating specialty – it addresses clinical problems from head to toe and has been a wellspring of surgical creativity and innovations for centuries. Its fundamental principles – wise planning of reconstruction, creative thinking and delicate operating – represent a rock upon which a plastic surgeon’s mindset is set, a solid foundation upon which all other, additional subspecialist expertise is built on later.
Malignant melanoma is a life threatening cancer which usually starts in the skin. More specifically, within the layer of skin which produces melanin (skin pigment), hence its name. It is less common than other skin cancers, however it is the most serious one. The cells, either in pre-existing moles or normal looking skin, begin to over-produce, grow beyond control causing an alteration in skin appearance. This is usually noted as a changing mole, irregular in outline or colour.
Although the cause is not fully understood, there is a strong evidence to suggest that ultraviolet (UV) radiation from the sun can do long-term damage to the skin, especially if skin is likely to burn following exposure to strong sunshine. People with positive family history of melanoma are also, at higher risk of developing this type of skin cancer.
Malignant melanomas caught in its early stage have a very good chance of cure. Timely diagnosis and quick treatment are crucial.
It is important to continue to examine your skin for any abnormal growths (new or old ones) to detect early warning signs and to be aware of things you can do to help yourself. Gallery below shows few examples of typical melanoma appearance to give you an idea what to look for.
Check for any existing or new skin lumps or moles that enlarge, change colour, bleed or itch. Most changes are harmless but they may indicate the start of a skin cancer. See your doctor if in doubt. The ABCD rule (see below) can help you remember what to look out for:
Asymmetry – the two halves of a melanoma may not look the same
Border – Edges of a melanoma may be irregular, blurred or jagged
Colour – The colour of a melanoma may be uneven, with more than one shade
Diameter – many melanomas are at least 6mm in diameter, the size of a pencil eraser
What can you do to reduce the risk of developing melanoma ?
- Take care whilst in the sun, by wearing protective clothing and using high factor sunscreens (SPF+)
- Wearing a hat with a large brim is recommended
- Avoid strong sunshine during 11am to 3pm if possible, especially over the summer months
- Avoid using sunbeds
- Pass on the message to friends and family about protecting themselves and checking alterations in moles and their skin.
- It is particularly important to protect children from strong sunlight
The best treatment is surgery. This involves removing the tumour completely and radically enough i.e. including a segment of normal, uninvolved nearby tissues.
Treatment protocol often involves two operations: first one when the original lesion is removed with a narrow margin of surrounding skin and the second one, when a further margin of skin from the original site needs to be excised. The second operation is performed only after the microscopic examination of the first specimen had been confirmed as melanoma. After the second, wider excision, tissue specimen is examined under a microscope again to ensure that no cancer cells have been left behind. This greatly reduces the risk of the melanoma recurring.
In most cases, it is possible to close the wound created by excision of original melanoma by simple suturing method. Sometimes however, it is necessary to repair the defect created by radical excision with a skin graft or skin flap as wound is too big for direct skin closure. Either reconstructive method aims to provide the most effective way of healing yet preserve tissue cosmesis as much as possible. Most operations for melanoma can be performed under local anaesthesia on a day care basis.
When the melanoma is removed surgically, the tissue specimen is sent for examination by pathologist in laboratory. One of the parameters assessed under the microscope is how deep, or thick tumour is. Breslow classification is most commonly used. In brief, tumours are divided into several categorise of tumour thickness which lie between 1-4mm. The thinner the melanoma, the lower is the risk of it spreading elsewhere in the body. Tumours with Breslow thickness under 1mm in most cases have a very favourable prognosis. In Britain, most people are diagnosed with a melanoma of less than 2mm in thickness, which have a good chance of a cure.
Some melanoma may spread to the lymph nodes. If the cancer cells escape (spread) from the original site, they are most likely to lodge in the lymph nodes. Lymph nodes are present throughout the body. We roughly know which particular group of nodes drains what area of the body so it is possible to focus clinical examination to group of nodes which are at the highest risk of being affected pending exact site of primary melanoma. For example, lesions arising in the leg are likely to spread to the groin first, melanoma on the upper limb into armpit glands, head lesions into the neck glands etc. Involved nodes may produce lumps, but their enlargement is often totally asymptomatic and not easy to pick up. Once the diagnosis is made that the lymph nodes are affected, removal of all nodes from that area (neck, armpit, groin) is recommended. I personally do not perform these types of operations any more, but I work very closely with expert colleagues who do and will ensure you are transferred under their care promptly if and when required.
It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:
- Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
- Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery
- Plan your time off school / work / sports
- Allow at least few weeks after surgery before considering travel
Following adequate surgery, no further treatment or investigations are usually required straight away. You will need to be followed up in the clinic on a regular basis for a certain period of time. Initially these are arranged to be every 3 to 6 months. Appointments will gradually tail off over the period between 3-5 years. The length of the follow up is determined by exact type of melanoma and individual medical circumstances.
Regular check-ups at the hospital are important to detect any recurrences at the site of removal, or in the surrounding area. Particular emphasis is put on examination of the local lymph node basins like armpits, groins, neck etc. Any dark spots that develop either at or near the site of removal of the melanoma should be reported if noted by the patients in the meantime.
It is possible for some melanomas to spread (metastasize) to other parts of the body and if this happens, further investigation and treatments may be needed. This includes surgery, radiotherapy, immunotherapy or chemotherapy. These treatments would usually take place in regional, designated skin cancer units.
Research and clinical trials are on going, aiming to develop newer and more effective treatments for melanoma, which you may be eligible for depending on your diagnosis.
Urgent concern after your surgery ?
Please ring the hospital where you have been operated on or my secretary and they will get in touch with me